Incontinence in Women - study group statement

Recommendations fall into three categories:

1. Recommendations for clinical practice (principally aimed at Fellows and Members of the Royal College of Obstetricians and Gynaecologists) based upon research evidence (where available) and the consensus view of the Group. The clinical practice recommendations have been graded from ‘A’ to ‘C’ according to the strength of evidence on which each is based (Table 33.1). The scheme for the grading of recommendations is based on the system adopted by both the NHS Executive and the Scottish Intercollegiate Guidelines Network.
2. Recommendations for future research in those clinical areas where the Group identified a need for further evidence on which to base practice.
3. Recommendations relating to health education and health policy.

Table 33.1. Grading of recommendations

Recommendations for clinical practice

Assessment

1. Basic assessment of the incontinent woman should include a comprehensive, systematic enquiry of all relevant factors including menopausal status, drug therapy and previous pelvic surgery and ano-rectal problems. (Grade C)
2. A pelvic examination must be performed and initial investigation should exclude urinary infection and monitor fluid input and output. (Grade C)
3. The management of faecal and urinary incontinence in physiologically fit older women should be the same as in younger individuals. (Grade B)
4. The coexistence of urinary and faecal incontinence is common and symptoms should be actively sought. (Grade B)
5. Assessment of pelvic-floor muscles and anal sphincter, of sensitivity to touch and pinprick in the perineal / perianal region, and eliciting the bulbocavernous reflex (BCR) and anal reflexes should be part of the clinical examination. (Grade C)
6. In selected patients, suspected to have a peripheral sacral neuromuscular lesion, a concentric needle electromyography (EMG) and recording of BCR are optional. (Grade C)
7. Patients suspected to have a generalised neurological condition should be referred to a neurologist. (Grade C)
8. Urodynamics (filling and voiding/pressure-flow cystometry) should be performed when voiding difficulty is suspected, when a neurological cause is suspected, if previous surgical treatments have failed, and prior to invasive (surgical) procedures. (Grade C)
9. Urodynamics must be performed with the emphasis on reproducing patient’s symptoms and by staff, fully trained to recognise and correct artefacts, and to interpret tracings. (Grade C)
10. If it is necessary to assess urethral function, either urethral closure pressures or abdominal leak-point pressures are appropriate. (Grade C)
11. Urine flow rate and post-void residual measurement are useful screening tests which indicate voiding dysfunction: only pressure-flow studies of voiding can define the cause of voiding dysfunction. (Grade C)
12. Urodynamics should be performed before surgical intervention to exclude voiding disorders and detrusor instability. (Grade B)
13. Imaging of the lower urinary tract allows structural information to be obtained. (Grade B)
14. When using X-ray, ultrasound or magnetic resonance imaging (MRI) to determine functional information this must be carried out in conjunction with urodynamic investigations. (Grade C)
15. Videocystourethrography may be useful in the investigation of neurogenic lower urinary tract dysfunction and after failed continence surgery. (Grade C)
16. Ultrasound measurement of bladder volumes is clinically useful. (Grade B)
17. Bladder wall thickness may be useful for the detection of detrusor overactivity as long as bladder outlet obstruction is excluded with uroflowmetry and post-void residual estimation. (Grade C)
18. There should be a standardised approach to the investigation of voiding difficulties. (Grade C)
19. Examination under anaesthesia, cystourethroscopy and dye testing remain the investigations of choice in suspected fistulae. (Grade C)
20. Urodynamic investigations will rarely alter the approach to management of urinary fistulae but may influence counselling. (Grade C)
21. Proper assessment and appropriate investigation should be mandatory before containment products are used long-term. (Grade C)

Treatment

1. Oestrogens cannot be used to treat stress incontinence. (Grade C)
2. Urgency, frequency and recurrent urinary tract infections in post menopausal women may be improved by the use of oestrogen therapy, especially vaginal oestrogens. (Grade C)
3. Older, frail people should not be excluded from surgical options for the management of their incontinence, but it should be recognised that a multidisciplinary approach to preoperative and postoperative care and rehabilitation must be promoted. (Grade C)
4. Simple management of diarrhoea and constipation in the frail elderly can be very effective. (Grade C)
5. Drug treatment for urinary incontinence in the elderly is as effective as in younger individuals. (Grade A)
6. Voiding difficulties following pelvic and particularly continence surgery and delivery are important causes of patient morbidity and litigation. Strict protocols on the management of patients before and after surgery and delivery need to be defined. (Grade C)
7. No postoperative or post-delivery patient should be left more than six hours without voiding or catheterisation. (Grade C)
8. Immediate management by catheter drainage should be advised for vesicovaginal and urethrovaginal fistulae of all aetiologies, at least until slough separates, and for up to eight weeks after initial presentation. (Grade B)
9. Both vaginal and abdominal procedures have a place in fistula management. Surgeons involved in fistula management should be capable of selecting and undertaking the most appropriate procedure for individual patients. (Grade C)
10. Interposition grafts may have a role in both abdominal and vaginal procedures, particularly for urethra or bladder neck, multiple or recurrent fistulae. (Grade B)
11. Urinary diversion should rarely be necessary in management of obstetric and surgical fistulae. It may be necessary in radiotherapy fistulae, but even here it should only be carried out after consideration of other options. (Grade C)
12. The small number of cases in the UK currently justifies centralisation of care on a supraregional basis, and fistula treatment should be undertaken by surgeons with appropriate training and experience. (Grade C)
13. Initial treatment for presumed genuine stress incontinence, detrusor instability and combinations of the two should include lifestyle interventions, pelvic-floor muscle training and bladder retraining. (Grade C)
14. Lifestyle interventions include weight and caffeine reduction, stopping smoking, treating constipation and regulating fluid intake. (Grade B)
15. Supervised pelvic-floor muscle training ideally should be for 15--20 weeks to achieve effect. (Grade A)
16. Bladder retraining is particularly indicated for presumed detrusor instability, though patients with combinations of presumed genuine stress incontinence and detrusor instability and genuine stress incontinence alone may also benefit. (Grade A)
17. Other physical therapy adjuncts/modalities (including biofeedback and electrical stimulation) and devices (intravaginal supporting, in particular) may be beneficial in selected cases, although it is not yet clear who might benefit most. (Grade C)
18. The addition of anti-muscarinics should be considered for patients with presumed detrusor instability and combinations of presumed detrusor instability and genuine stress incontinence, with no improvement with the above therapies. (Grade B)
19. The above initial therapies should be maintained (on average) for approximately 15--20 weeks before possible specialist referral for lack of improvement. (Grade B)
20. Suprapubic catheterisation is the preferred route for long-term indwelling catheterisation. (Grade C)
21. When appropriate, clean intermittent self-catheterisation should be considered. (Grade C)
22. All patients contemplating surgery for stress urinary incontinence should be offered a trial of physiotherapy. (Grade C)
23. All surgical procedures should be undertaken only by those with appropriate training and experience to allow them to maintain the highest standards of practice. A sufficient caseload is necessary, as recommended by the Department of Health document on ‘Good Practice in Continence Services’ (2000). (Grade C)
24. Informed consent in relation to surgery for incontinence should include available evidence in relation to outcomes and complications, and the extent of local experience with the procedure or device. (Grade C)
25. Advanced surgical or reconstruction techniques for urinary incontinence should be carried out in specialist centres, after multidisciplinary discussion, and equally after the patient has been fully counselled. (Grade C)

Pregnancy

1. Episiotomy does not appear to protect the pelvic floor or prevent stress incontinence. (Grade B)
2. Caesarean section is not completely protective against urinary and faecal incontinence. (Grade B)
3. Postnatal pelvic-floor exercises are effective in reducing urinary incontinence. (Grade A)
4. Antenatal pelvic-floor exercises are effective in risk groups. (Grade A)
5. Treat complex gastrointestinal disease during pregnancy in co-operation with the appropriate specialist. (Grade C)
6. In cases of abdominal pain during pregnancy when acute appendicitis is considered, appropriate and prompt surgery poses less risk than waiting. (Grade C)
7. Persistent gastrointestinal tract motility disorders require prompt investigation – changes are often permanent. (Grade C)
8. Patients with prolapsed thrombosed external haemorrhoids should be urgently referred for incision. (Grade C)
9. We need to know the effects of standard gastrointestinal therapies on pregnancy, the fetus and breast feeding. (Grade C)
10. Repair of anal sphincter tears should only be performed by an appropriately trained clinician or a clinician under supervision. (Grade C)
11. The facilities, equipment and support for third-degree repair should form part of a standard protocol and should be available in every labour ward. (Grade C)
12. An end-to-end or overlap repair of the external sphincter are both acceptable techniques of immediate repair. (Grade C)
13. Most women with postpartum faecal incontinence should be managed conservatively. (Grade C)
14. Isolated and delayed defects of the external anal sphincter should be repaired using overlapping techniques. (Grade C)
15. Uncertain role for total pelvic-floor repairs and unstimulated muscle transposition as surgical procedures for faecal incontinence. (Grade C)
16. Caesarean section may be more appropriate in a ‘compromised but continent’ group such as women who have previously had surgery for bladder or bowel dysfunction or women who have co-existing morbidity such as detrusor instability. (Grade C)

Research

Basic research on pelvic-floor structure and function

1. A better understanding of the variation in normal anatomy of urethral structure, urethral support and pelvic-floor tissues, at cellular and macroscopic levels, is necessary. We need to identify the anatomical changes that render a woman more vulnerable to developing stress urinary incontinence and/or prolapse.
2. Research in vivo is needed into whether the reduced maximal urethral closure pressure identified using urodynamics in postnatal women is due to muscle fibre loss.
3. We need to determine whether the imaging modalities of magnetic resonance and ultrasound accurately and reliably depict the fascial or muscle defects associated with stress urinary incontinence and prolapse, or changes in function related to urodynamic findings.
4. We need to establish whether neurogenic insufficiency of pelvic-floor muscles is not only a consequence of loss of strength, but also of coordinated function.
5. Pelvic-floor muscle activity patterns should be elucidated using kinesiological EMG and/or imaging.
6. Validation and standardisation of clinical neurophysiological tests are needed to reveal involvement of striated and smooth muscle, somatic and autonomic innervation.
7. Ultrasound and MRI of the tissues surrounding the urethra should be carried out to correlate their quantity and quality in relation to urodynamic findings. There needs to be more research into the aetiology of women who present with chronic non-neurogenic urinary retention (and particularly the subgroup in whom abnormal spontaneous EMG activity takes the form of complex repetitive discharges and deceleration bursts that can be demonstrated in the striated urethral sphincter – ‘Fowler’s syndrome’).

Diagnosis and treatment

1. There needs to be more research into the aetiology of women who present with chronic non-neurogenic urinary retention.
2. We should encourage research into the cellular and histopathological features of urgency frequency syndrome which may optimise treatment.
3. Research is needed on how pregnancy and delivery affect urinary (and faecal) continence, whether at-risk groups can be identified and what happens after long-term follow-up.
4. Further studies, preferably with large randomised controlled trials, are needed to compare anticholinergic drugs and the long-term outcomes of treatment.
5. More research is required regarding the best type of oestrogen, route of administration and duration of therapy.
6. There is a need for field trials of conservative therapies in the elderly who are functionally and cognitively impaired.
7. There is a need for trials of new drug therapies in elderly populations that reflect the general population from which they come.
8. The potential effect of treatment of incontinence upon other diseases in the elderly, e.g. falls, stroke, depression should be recognised, systematically researched and promoted.
9. All new anti-incontinence devices need to be assessed for efficacy and safety in clinical trials before commercial marketing to the public.
10. Neuromodulation and other electrostimulatory techniques for urinary and faecal incontinence need further evaluation.
11. More research is needed to find out how much exercise is needed to improve and maintain optimal pelvic-floor muscle function, and to evaluate the effect of pelvic-floor muscle training in urge incontinence and primary prevention.
12. We need to standardise how surgical outcome is assessed and how long after the procedure it should be made.
13. We need more data on how confounding variables such as age, obesity, previous surgery and coincidental hysterectomy will influence choice of surgical method and outcome. Further assessment in appropriately designed surgical trials is necessary to determine the role of laparoscopic surgery.
14. Research is required on nonsurgical treatment of faecal incontinence following pregnancy.
15. There is a need for more data to support decisions with regard to prophylactic caesarean section.
16. Evidence is available that surgical procedures, implants and devices for incontinence are less than perfect in terms of efficacy and acceptability. We would wish to encourage collaboration with industry in the research and development of such procedures.
17. We recommend that all new surgical devices and implants are strictly restricted initially, to application within the context of research trials, and preferably randomised controlled trials with appropriate methodology and follow-up. Only when the safety and efficacy are reasonably established should such restrictions be lifted, and marketing be approved.

Health policy and education

General

1. The new International Continence Society (ICS) classification for urinary incontinence should be employed to allow more effective communication.
2. There need to be reasonably tight definitions for acute retention and chronic retention as outlined within the new ICS classification.
3. There is a classification of causation of voiding difficulties that is a reference point and, within that, the topic of psychogenic should be rewritten as ‘dysfunctional voiding’.
4. We should recognise that urgency--frequency syndrome is a diagnosis of exclusion of both organic and non-organic pathology.
5. We need to recognise the possibility of other pelvic syndromes producing lower urinary tract symptoms, i.e. endometriosis and genital atrophy.
6. National and international strategies should support initiatives in areas of high prevalence to eradicate those practices shown to be contributory to fistula development.
7. Mobilisation of the bladder and inability to clearly define the course of the ureter increase the risks of urinary tract damage at hysterectomy.
8. The high cost of many anti-incontinence devices affects availability.
9. Pelvic-floor muscle training has no serious, if any, adverse effects and women should be motivated to perform pelvic-floor muscle exercises intensively as the first choice of treatment. However, more than 30% do not contract correctly at their first consultation and thorough individual instruction is needed. Manual techniques and electrical stimulation may be used to teach how to contract.
10. Surgical technique is far from standardised. We need to specify material used, the number of sutures on each side, where they are positioned and so on before comparisons can be made.
11. Since there is some evidence that surgical experience influences outcome, it is important that appropriate training is undertaken before laparoscopic colposuspensions are performed.
12. It appears that those units performing a significant number of continence surgical procedures get better results.
13. Advanced surgical or reconstruction techniques for urinary incontinence should be a final resort as they are associated with significant morbidity.

Relevant to pregnancy

1. Every booked antenatal patient should be asked about urinary and faecal continence.
2. In order to interpret post-delivery symptoms, relevant gastrointestinal and urinary tract symptoms must be known in early pregnancy.
3. We must promote the role of antenatal and postnatal pelvic-floor exercises with public and patient information.
4. Prepregnancy advice, to include the effects of pregnancy and mode of delivery, should be given to patients after successful management of urinary or faecal incontinence to allow discussion before contemplating the next pregnancy.
5. The new classification of perineal tears due to be published in the RCOG guidelines should be implemented.
6. Attendance at perineal repair workshops should become part of modular training in a specialist registrar’s programme.
7. The majority of women who develop urinary symptoms do so antenatally.
8. Caesarean section rates have more than quadrupled over the last 25 years, but the prevalence of incontinence has not fallen.
9. Pregnancy per se and delivery appear to be equally responsible for the risk of urinary symptoms; increasing parity increases these risks. Therefore the risks of several caesarean sections and the size of planned family would have to be included in the assessment.
10. This Study Group recommends a national register of new procedures, such as implanted devices, to record outcomes and complications, along the lines of the ‘yellow card’ system for recording adverse drug events.
11. The current regulatory processes for the introduction of new surgical procedures into clinical practice cause concern. The Study Group does not believe that SERNIP provides effective regulation and NICE is probably not yet sufficiently responsive to such developments.

Reference

Recommendations arising from the 42nd Study Group: Incontinence in Women. In: MacLean AB, Cardozo L, editors. Incontinence in Women. London: Royal College of Obstetricians and Gynaecologists Press; 2002. P.433--41.